CPSS - Life Insurance
Agents on case:
*
Agent Name:
Agent ID
% Split:
Promotion Level
NPN #:
Last 4 SSN:
Are you licensed/appointed?
Phone number/Email:
How long have you known the insured?
Relationship to Insured:
Writing agent:
TA
A
SA
MD
SMD+
Yes
No (I will apply today)
Agent
Relative
Friend
Split agent:
TA
A
SA
MD
SMD+
Yes
No (I will apply today)
Agent
Relative
Friend
Product(s) you are recommending (Select all that apply):
*
Transamerica Super Term
Transamerica Trendsetter Term
Transamerica FFIUL
Transamerica Final Expense
Nationwide Term
Nationwide IUL
Pacific Life Term
Pacific Life IUL
North American Product
Allianz Product
Other Crump Product (IUL/Term)
Symetra (AMS)
Everest-IA American
Other (Add in notes section)
Insured Information:
*
Insured #1
Insured #2
Insured #3
Insured #4
First Name
Middle Name
Last Name
Gender
DOB
SSN
Address
Phone number
Birth State
US Citizen?
If not US Citizen, which country?
Marital Status
Email Address:
Years at current address:
Insured Identification:
*
Insured #1
Insured #2
Insured #3
Insured #4
Form of ID:
State of Issue:
ID Number:
Expiration Date:
Height/Weight Information
*
Insured #1
Insured #2
Insured #3
Insured #4
Current Height
Current Weight
Weight 1 year ago
Reason for weight change
Owner Information (If different from insured):
Owner #1
Owner #2
First Name
Middle Name
Last Name
Gender
DOB
SSN
Address
Phone number
Birth State
US Citizen?
Marital Status
Email Address:
Years at current address:
Insureds name they are an owner for
Owners Identification (If different from insured):
Owner #1
Owner #2
Form of ID:
State of Issue:
ID Number:
Expiration Date:
Physician Information:
Insured #1
Insured #2
Insured #3
Insured #4
Physician Name:
Phone Number:
Address:
Date Last Seen:
Reason last seen:
Result:
Non-Medical Information (Please select all that apply to insureds and explain):
Insured #1
Insured #2
Insured #3
Insured #4
Notes:
Seizure, fainting, stroke, loss of consciousness, tremor, paralysis, multiple sclerosis, epilepsy?
High blood pressure, heart attack, murmur, palpitation, or anemia or any disease of the heart, blood vessels or blood?
Asthma, chronic bronchitis, pneumonia, emphysema, tuberculosis or any disease or abnormality of the lungs, bronchial tubes or respiratory system?
Ulcer, colitis, hepatitis, cirrhosis, or any disease of the esophagus, stomach, intestines, rectum, gallbladder or liver?
Treated or counseled for the use of alcohol, drugs or other substance?
Diabetes or any disease or abnormality of the thyroid, adrenal, pituitary or other glands?
Sugar, protein or blood in urine, sexually transmitted disease, stone or any disease of the kidney, bladder, prostate, breasts, ovaries or reproductive system?
Arthritis, gout, connective tissue disease, back trouble or any disease or abnormality of the joints, muscles or bones?
Disease/abnormality eyes, ears, nose, throat skin
Cancer, tumor, polyp or cyst?
Any physical deformity or amputation?
Anxiety, depression, suicide attempt or any psychiatric, mental or emotional condition?
Any immune deficiency disorder, (AIDS), (ARC), (HIV), or test positive on an AIDS/HIV-related test?
Within the past ten years, have you ever used marijuana, sedatives, amphetamines, barbiturates, morphine, cocaine/crack, methamphetamine, Ecstacy (MDMA), heroin, LSD, PCP, any hallucinogenic drug or narcotic drug except as prescribed by a physician?
Other than what has already been disclosed, within the past 5 years have you:
Insured #1
Insured #2
Insured #3
Insured #4
Had or been advised to have an X-ray, electrocardiogram, laboratory test or other diagnostic study?
Had or been advised to have a surgical procedure?
Dizziness, shortness of breath, pain or pressure in the chest, or persistent fever?
Injury requiring treatment?
Taking prescription, vitamin, supplement or over-the-counter medication?
Parents, brothers, sisters, ever had cancer, diabetes, heart disease, mental illness or attempted suicide?
Weight changed by more than 15 pounds?
Life Application declined, withdrawn, postponed, rated, modified, cancelled?
Pregnant?
If any of the boxes above are checked, please provide details below for each medical condition:
Condition 1
Condition 2
Condition 3
Condition 4
Condition 5
Insured Name
Medical Condition
Date Diagnosed
Duration
Treatments
Results of treatment
Medication
Dosage
Frequency
Doctor Name/address of whose providing treatment
Family History (only required for Transamerica Term/Symetra policies): **If additional siblings exist, please enter in the notes section.
Father: (Living/Deceased, Age, Current Health)
Mother: (Living/Deceased, Age, Current Health)
Sister: (Living/Deceased, Age, Current Health)
Sister: (Living/Deceased, Age, Current Health)
Brother: (Living/Deceased, Age, Current Health)
Brother: (Living/Deceased, Age, Current Health)
Insured 1
Insured 2
Insured 3
Insured 4
Last 2 years:
*
Insured 1
Insured 2
Insured 3
Insured 4
Notes:
Any Nicotine? (If yes please explain what type/frequency)
Regular weekly exercise?
Participate in Athletics?
Do you have pets?
Regular exams by your physician?
Regular Dental Checkups?
Are you a member of a social group or volunteer for charity work?
Background and Activities (If yes, please provide notes in the notes section):
Insured 1
Insured 2
Insured 3
Insured 4
Notes:
Pilot
Military
Rodeo
Organized Racing
Mountain Climbing
Competitive Skiing
Skydiving
DL Violation in the past 5 years?
Felony/Misdem?
Do you have any plan to travel outside of the US in the next year?
Current Insurance Coverage:
Policy 1
Policy 2
Policy 3
Policy 4
Name of Insured:
Carrier
Type
Coverage Amount
Year Purchased
Monthly Premium
Policy Number
Is this insurance a replacement?
Is this policy being 1035 exchanged?
Beneficiary Information:
*
Primary/Contingent
Name
DOB
SSN
Address
%
Relationship to the Insured
Insured 1
Primary
Contingent
Insured 1
Primary
Contingent
Insured 1
Primary
Contingent
Insured 2
Primary
Contingent
Insured 2
Primary
Contingent
Insured 2
Primary
Contingent
Insured 3
Primary
Contingent
Insured 3
Primary
Contingent
Insured 3
Primary
Contingent
Insured 4
Primary
Contingent
Insured 4
Primary
Contingent
Insured 4
Primary
Contingent
Insured 4
Primary
Contingent
Employment Information:
*
Insured 1
Insured 2
Insured 3
Insured 4
Employer
Position
Address
Phone Number
Annual Income
Net worth
Bank Information:
*
Insured 1
Insured 2
Insured 3
Insured 4
Payors Name
Initial Planned Premium
Is there a lump sum amount?
Frequency
Draft Date (policy effective date is preferred)
Bank Name
Checking or Savings?
Routing #
Account #
Are you submitting money with the application?
Additional Notes:
Illustration:
*
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